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    Annual Review-Certificate of Violations PDF

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    Darion Lewis

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    © All Rights Reserved
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    Annual Review-Certificate of Violations PDF

    Uploaded by

    Darion Lewis
    197 views1 page

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    Annual Review-Certificate of Violations.pdf

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    197 views1 page

    Annual Review-Certificate of Violations PDF

    Uploaded by

    Darion Lewis

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    MOTOR VEHICLE DRIVER’S

    Certification of Violations/Annual Review of Driving Record


    MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of
    all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of
    which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31
    need not repeat that information on this form.
    DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or
    collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

    COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS


    NAME OF DRIVER: (PRINT) ID NUMBER DATE OF EMPLOYMENT

    HOME TERMINAL (CITY AND STATE) DRIVER’S LICENSE NUMBER STATE EXPIRATION DATE

    I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided
    under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.
    (If you have had no violations, check the following box – None.)
    DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED

    If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation
    (other than those I have provided under Part 383) required to be listed during the past 12 months.

    Date Driver’s Signature

    COMPLETED BY MOTOR CARRIER - ANNUAL REVIEW OF DRIVING RECORD


    MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor
    Carrier Safety Regulations. Complete the information requested below.

    I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she
    (check one):

    Meets minimum requirements for safe driving Is disqualified to drive a motor vehicle pursuant to Section 391.15

    Does not adequately meet satisfactory safe driving performance

    Action taken with driver:

    Reviewed by:
    Signature Date

    Printed Name Title

    Motor Carrier Name Motor Carrier Address


    MAINTAIN THIS DOCUMENT IN THE DRIVER’S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATE OF EXECUTION.

    © Copyright 2008 J. J. KELLER & ASSOCIATES, INC., Neenah, WI • USA • (800) 327-6868 • jjkeller.com 643-F 3685 (11/08)

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